The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?
Attempt to deescalate the client.
Continue to observe the client for increased agitation.
Offer medications to help the client control behavior.
Ensure safety in the environment for the client and others.
The Correct Answer is D
A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Tardive dyskinesia is a side effect of long-term neuroleptic (antipsychotic) treatment. It is characterized by involuntary, repetitive movements, particularly of the face and tongue. This condition is more commonly seen in clients who have been on neuroleptics for extended periods.
B) Incorrect. Discontinuing neuroleptic treatment may lead to withdrawal symptoms or symptom recurrence, but it does not directly increase the risk of developing tardive dyskinesia.
C) Incorrect. Neuroleptic malignant syndrome (NMS) is a different side effect associated with neuroleptic medications, characterized by hyperthermia, autonomic dysregulation, altered mental status, and generalized muscle rigidity.
D) Incorrect. Monoamine oxidase inhibitors (MAOIs) are a different class of medications and are not associated with the development of tardive dyskinesia.
Correct Answer is D
Explanation
A) Incorrect. Delusions of reference involve a belief that everyday events, objects, or other people have a particular and unusual significance. This is not described in the scenario.
B) Incorrect. Tangentiality is a thought disorder where the individual goes off on tangents and never returns to the original point or idea. This is not described in the scenario.
C) Incorrect. Neologism refers to the creation of new words or phrases that have meaning only to the person using them. This is not described in the scenario.
D) Correct. Loose associations are characterized by a disruption in the logical progression of thought, where thoughts become disorganized and may seem unrelated or loosely connected.
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